Other Elbow Concerns in Overhead Athletes

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1 Other Elbow Concerns in Overhead Athletes John A. Steubs, M.D. Team Physician, Minnesota Twins TRIA Orthopaedic Center Disclosures None relevant to this presentation. Other Elbow Problems Valgus extension overload Ulnar nerve issues Medial/lateral epicondylitis Olecranon stress reactions Radial tunnel syndrome Capitellar OCD Radiocapitellar plica Medial epicondyle avulsion

2 Valgus Extension Overload Valgus Extension Overload Large forces generated 64 N-mm valgus force 500 N compressive force Tensile force medially and shear stress in the posterior compartment Produces olecranon tip osteophytes, loose bodies, and kissing lesion; i.e., chondromalacia of posteromedial trochlea Positive valgus extension overload test Positive bounce test Decreased elbow extension Andrews, et al., AJSM, 1995 VEO most common diagnosis requiring surgery in baseball players Valgus Extension Overload - Radiographs Articular damage Olecranon osteophyte +/- loose bodies UCL pathology Valgus Extension Overload Operative Rx Careful assessment anteriorly valgus stress test at 70 degrees - <1-2 mm opening Loose body removal Olecranon osteophyte removal no greater than 3-5 mm Reddy, et al., Arthroscopy, elbow arthroscopies 92% good or excellent 85% professional RTP

3 Valgus Extension Overload Ulnar Nerve Issues - Etiology Cohen, et al., Arthroscopy, 2011 Scope, osteophyte debridement, loose bodies 8-9 RTP at 12 weeks 5-21% post excision UCLR Ulnar nerve instability (16%) Compression at cubital tunnel Muscle entrapment Medial triceps Anconeus epitrochlearis Flexor carpi ulnaris Osteophytes UCL instability Ulnar Nerve Symptoms and Exam Ulnar Nerve Treatment Non-operative Paresthesias in ring and little finger Ulnar nerve tenderness Positive Tinel s sign Nerve subluxation Rest, NSAIDs Physical therapy Gradual return (often up to 6 weeks)

4 Ulnar Nerve Treatment Operative Ulnar nerve transposition Submuscular, Del Pizzo, et al., AJSM 6% RTP Subcutaneous, Reggit and Eblen, AJSM, % RTS at average 12.6 weeks If UCL laxity Address UCL laxity Transpose ulnar nerve, Jobe, et al., Conway, et al., 31% and 21% postop nerve dysfunction with submuscular transposition Ulnar Nerve Transposition - Technique Release Arcade of Struthers Cubital Tunnel Release FCU 2-3 cm release Excise segment of intermuscular septum Fascial sling Avulsion/Apophysitis Up to 20% of elbow fractures, Gottschalk, et al., 2012, Jam Acad Ortho Surg. 58% of older adolescent pitches experience medial elbow pain, Grana and Rashkin, AJSM, 1980 Last ossification center to fuse years of age Site of attachment of both UCL and flexor pronator mass Avulsion -Evaluation Observation swelling and ecchymosis Palpation flexor pronator, ulnar neve, medial epicondyle, UCL Neurovascular exam Plain radiographs CT or MRI if questionable displacement, especially in throwing athletes

5 Avulsion Anterior displacement UCL loose in flexion Tight in extension Consider ORIF in high powered overhead athlete Avulsion Non-operative management, Cruz et al., Ped Ortho, 2016 Minimally displaced 5 mm No valgus instability Long arm cast degrees for 2-4 weeks Removable splint for ROM Hinged elbow brace at 6 weeks Return when pain free, full ROM and radiographic union Avulsion Operative Treatment Displacement >5 mm Fracture elbow dislocation Incarcerated fragment Valgus instability/laxity Ulnar nerve entrapment Fracture Technique Prone patient 4.5 mm cannulated screw Central placement Avoid olecranon fossa Protect ulnar nerve

6 Avulsion Results Lawrence, et al., AJSM, athletes; 14 operative, 6 non-operative. 100% RTP both groups Case, et al., AJSM, patients treated with ORIF and screw Fracture displacement >5 mm 100% RTS Repetitive micro-trauma caused by impingement Rare injury Posterior olecranon pain during and after throwing Tender along proximal ulna Radiographic evaluation Plain films often normal Bone scan MRI allows for evaluation of UCL CT scan Non-operative treatment Rest Bone stimulator Nuber, et al., Clin Ortho, 1992, 2 successful non-operative Schickendantz, et al., AJSM, 2002; 7 professional baseball players, 100% RTP

7 Summary Operative management Axial compression screws +/- bone grafting. 6.5 or 7.3 mm Plate fixation usually for revisions or displacement Paci, et al., AJSM, baseball players cannulated screw RTP 22% subsequent UCLR VEO associated with variable degree of UCL insufficiency Olecranon stress fractures also often associated with subsequent UCL tears Ulnar nerve issues arise from a variety of causes, often intrinsic Fix most medial epicondyle fractures, especially in high performance throwers